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Select Type:

Status:

Insured's Particulars

Name of Insured:

NRIC/Passport #: Nationality:

Date of Birth: Marital Status:

Sex:

Occupation: Location:

Driver's Lic. Issue Date (Pass Date):

Contact Number: Email:

Business's Particulars

Business Name: Business Description:

Occupation: Location:

Usage: Carry Own Goods:

Contact Number: Email:

Current Insurer's Particulars

Existing Insurer: Expiry:

NCD %(Upon Renewal): Safe Driver Discount:

Renewal Premium:

Claims (Last 3 years):

Vehicle Particulars

Cover: Vehicle Registration #:

Make And Model: Body Type:

With Hood:

Laden Weight: Unladen Weigth:

Engine Capacity (cc):

Parallel Import: No. Of Seater:

Finance Company:

Named Driver's Particulars

Named Driver 1 Name: NRIC/Passport #:

Date of Birth: Marital Status:

Sex:

Occupation: Location:

Driver's Lic. Issue Date (Pass Date): Relation:

Named Driver 2 Name: NRIC/Passport #:

Date of Birth: Marital Status:

Sex:

Occupation: Location:

Driver's Lic. Issue Date (Pass Date): Relation: